Your Rights as a Patient
Access to Care
- Receive care regardless of race, gender, religion, or national origin
- Obtain emergency care when medically necessary
- Know the names and roles of your healthcare providers
Information and Communication
- Receive complete information about your diagnosis, treatment, and prognosis
- Access your medical records as permitted by law
- Receive clear explanations about procedures and informed consent
- Get detailed information about fees and payment policies
Participation in Treatment Decisions
- Participate in decisions about your care
- Refuse treatment as permitted by law
- Receive information about advance directives
- Request a second opinion
Privacy and Confidentiality
- Have your medical information kept confidential
- Privacy during examinations and procedures
- Review your records with a healthcare provider
Your Responsibilities as a Patient
Providing Information
- Provide accurate medical history
- Inform staff about current medications
- Report changes in your health status
- Notify staff of previous dental work
Following Treatment Plans
- Follow pre-operative instructions
- Comply with post-operative care guidelines
- Take prescribed medications as directed
- Attend scheduled follow-up appointments
Financial Obligations
- Provide accurate insurance information
- Pay agreed-upon fees
- Notify office of inability to keep appointments
- Understand your insurance coverage
Behavior and Conduct
- Treat staff with respect and courtesy
- Arrive on time for appointments
- Follow facility rules and regulations
- Refrain from disruptive behavior
Acknowledgment
I have read and understand my rights and responsibilities as outlined above.
Patient Name: ____________________
Signature: _______________________
Date: ___________________________